Jonathon Tomlinson: “Four problems”—a typical day for a GP

May 2, 2014

I had only three patients left to see at the end of my morning surgery. It was 12.30. I had started at 8am, taking urgent phone calls for an hour before starting face to face appointments. It had been a typically challenging morning. Many patients had complicated mixtures of physical, mental, and social problems which is typical of all general practice, especially in deprived areas like Hackney. As a result I was running about half an hour behind and feeling pretty harried.

My next patient was a young, healthy looking, smartly dressed woman, in contrast to my previous patient, an elderly Turkish man with depression and chronic back pain who didn’t speak a word of English and came without an interpreter. The young woman was cheerful and friendly. “This shouldn’t take too long,” I thought as I called her in.

My heart sank some more. Any consultation that starts with the promise of brevity is guaranteed to exceed its allotted time. I looked her in the eyes, gestured for her to sit down and smiled with warmth and empathy, and greeted her with the words I use about forty times a day,

“Hello, my name is Jonathon Tomlinson, I’m sorry to keep you waiting, how can I help?”

“Hi Jonathon, I’m Charlotte, I hope you don’t mind, but I’ve got four things I’d like to discuss this morning, they’ll all be quick.”

“Of course” I lied, shifting my expression from a smile of greeting to friendly concern, “Can you tell me what they are?”

“Well the first one’s easy, I just need a repeat of my prescription, the second one is my knee, you see it’s been hurting after I go running, after about three or four miles it’s really hard to go on. And the other one is about my irritable bowel, my nutritionist says I need some blood tests and she’s given me a list to give to you.”

As she rumaged in her bag for the list of blood tests, I glanced at the computer. Alerts were flashing up demanding that I asked her about her smoking status and alcohol consumption, checked her weight and blood pressure, screened her for depression and offered her a smear. I scowled at it and turned off the screen so that it couldn’t irritate me any more.

“Here you are” she said helpfully, handing me a list of about a dozen blood tests, few of which I would have recommended myself and a few of which I had no idea if our local lab could even test for. There was no information from the nutritionist—who she had seen privately—about why she thought the tests were necessary. Unlike dieticians, who need a degree, are state-registered and work with us all the time, nutritionists have variable training, are unregulated and don’t work for the NHS. “Thanks”, I said taking the list and putting it on my desk. The symptoms of irritable bowel syndrome vary considerably between different people. For some, it causes severe abdominal cramps, pain and bloating, sudden, unpredictable bouts of diarrhoea with urgency—so that when sufferers need to go, they really need to go. It makes them tired and miserable and in some cases depressed and anxious. I’m very sympathetic. But I cannot justify the time and money involved in arranging the blood tests her nutritionist wants. Unlike the nutritionist, I am responsible for not only the costs, but I will have to justify them to the lab and take responsibility for acting on the results.

It’s a situation I’ve come across before. Previously patients have understood my concerns, but only after spending a long time taking a detailed history of their symptoms and exploring the impact on their life and relationships. Only when they believe that I am as interested in their symptoms, as concerned and as keen to help as their nutritionist, is it possible to broach the subject of why I’m not going to organise the blood tests.

All this is worrying me, mostly because of how long it’s going to take. When I say, “Shall I have a look at your knee?” I gesture to the couch. She had to take off her boots and jeans so that I can examine her knee. I was expecting her to have a common condition called patello-femoral pain syndrome so I was surprised to see that her knee was swollen and warm. After a careful examination and asking several more questions I’m concerned that there is something more serious going on and have to continue to examine the rest of her joints before she gets dressed again. As she gets dressed I explain my concerns and what I think we need to do. I’m concerned about an inflammatory arthritis and think she should have some blood tests and see a rheumatologist. I imagine myself arguing with an invisible health policy wonk who is standing in the corner of the room accusing me of inexcusable paternalism and contempt for patient choice as I recommend that I do the blood test now and refer her directly to our excellent local rheumatologist. I’m in a bad mood.

By now the consultation has gone on for over 15 minutes. In another 15 minutes it will be 1pm and a health visitor will be here to discuss a child protection case we’re both very worried about. There are two patients left to see. I start to panic. I’m feeling irritable and anxious.

I smile.

“What was the prescription you needed?”

“My pill”

Her review is overdue, so I need to check her blood pressure. I use the 90 seconds it takes to ask her about her smoking and alcohol consumption, but the blood pressure machine is confused if patients talk when it’s measuring, so I have to do it again. I collect the bottles for the blood tests in silence while the machine beeps happily.

Charlotte asks if I can do the blood tests her nutritionist has requested at the same time as the tests for her arthritis.

I lie.

“I can do some of them, I’m not sure if they’re all available at our local lab”

There are some I don’t want to do, because they’re not necessary.

I feel bad about lying.

I tell her the truth.

“Some of the blood tests your nutritionist has asked for I think are really useful for someone with your symptoms, but some really aren’t and there’s one missing which I think you need.”

“That’s ok,” she says, “I think I trust you more than the nutritionist.”

I’m extraordinarily relieved, I want to hug her and tell her she’s made my day.

But I don’t.

I do the blood test. I’ve taken over 20 minutes. It’s gone ten to one. A message on my screen pops up to say the health visitor is here. I start to get anxious again.

“There was one more thing” she says.

I was hoping she might have forgotten. Usually when patients have something serious to discuss, especially if it’s something embarrassing, they save it until last. Quite often they get up to leave, walk to the door, open it, pause, turn around and say, … “I was just wondering about the lump in my breast/ blood in my pee/ sudden loss of vision/ terrible crushing chest pain, etc.”

I can’t let it go.

“What was it?” I ask with gentle concern. I’m feeling benevolent in spite of the time, because of what she said about trusting me more than the nutritionist.

“My brother died last month, he was knocked off his bike and run over. I haven’t been able to sleep and I keep crying all the time, I’m not coping with work and I was wondering if I could have a bit of time off.”

“I’m so, so sorry. We should meet again though, when we’ve got a bit more time. Can I give you a note for a week and we’ll meet again then?”

Tears are rolling down her cheeks, “Thanks so much, I really appreciate that.”

I felt incredibly sad as she left. Not just because I was still imagining what it must be like to have lost her brother, but because nobody in policy—such those behind last week’s report into the future of Primary Care—seems to understand what it is we GPs do all day. The gap between their proposals for more technology and our need for more time and human interaction seem to be getting wider than ever.

I know I don’t have any free appointments in a week. So I arrange to see her 15 minutes before my evening surgery starts. Almost every surgery has extra patients booked before it starts and after it’s supposed to finish.

It’s five to one when I step out into the waiting room. The health visitor looks up and waves. A middle aged man is asking the receptionist when he’s going to be seen. An elderly man has fallen asleep in a wheelchair, his carer has left and promised to come back to collect him at 1pm. He is my next patient. I wheel him into my room. He thinks he might have broken his hip.

Post script: My next patient had broken his hip, it took nearly 20 minutes to help him to get from his wheelchair onto the couch, undress him, examine him, dress him again, and arrange for him to go to hospital. When I finished, I found my last patient had left after making a complaint. There was a message from the practice manager asking me to discuss it with her. It’s my third complaint this month.

It was nearly 1.20 when I finished. The health visitor was standing up looking concerned. We had only 10 minutes to discuss the child protection case.

The patients in this blog are all fictional.

Competing interests: None declared.

Jonathon Tomlinson is a GP at the Lawson Practice in London and a NIHR In Practice research fellow, studying moral development in medical education at the Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry. He has been teaching medical students in clinical skills, medical ethics, and medicine in society since 2003 and writes a blog about the relationships between doctors, patients, and society at http://abetternhs.wordpress.com/

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